Improving Health Service Delivery Through Community Monitoring and Non-Financial Awards
In many developing countries, the health sector suffers from a severe human resources problem due to staff shortages and absenteeism. The availability of health care workers is a crucial element of quality care and the existing high levels of absenteeism represent a major leakage in health sector resources. Policy-makers have focused their attention on performance-based financing to incentivize attendance and performance monetarily; however, the evidence on the impact of financial incentives in improving performance in the health sector is mixed. While some programs report positive results, others show little to no effect on attendance and outcomes.
In contrast, recent results have highlighted the power of non-financial incentives to reduce absenteeism and improve performance. Evidence suggests that peer recognition and status-based incentives can be more motivational, less expensive and less likely to erode intrinsic motivation. In addition, another study implementing a community monitoring initiative in Uganda, in which community members and health workers jointly addressed obstacles to adequate healthcare provision. The study found that under-five mortality was 33 percent lower in treatment compared to comparison communities a year later, while utilization for general outpatient services was 20 percent higher.
Yet, the finding that non-financial incentives such as community monitoring improve clinic performance leaves a crucial question unanswered: does community monitoring improve clinic performance because it is a bottom-up intervention which makes clinic personnel socially accountable to their immediate neighbors? Or does it work simply because clinic performance is being monitored and evaluated? The answer to this question is important as top-down monitoring may be potentially cheaper and more efficient than bottom-up monitoring; however, data on this crucial question is lacking.
Sierra Leone’s health indicators are among the lowest in the world, and the country’s health system is plagued by such chronic worker absenteeism, resulting in part from a lack of accountability between service providers and patients, and the weak incentives healthworkers face. Alongside a national decentralization program introduced in 2004, the Government of Sierra Leone launched an ambitious policy in 2010 to institute free healthcare for pregnant women, new mothers and children under-five. The policy abolished user fees, while at the same time raising workers’ salaries. However, these reforms occurred without introducing institutional features to improve oversight of health workers or changing underlying incentive systems, leaving the health sector at risk of further weakening in response to rising demand for free health services.
This project evaluates two social accountability interventions aimed at improving health service delivery via community monitoring and the introduction of an incentive scheme to reward worker performance on the basis of non-financial awards. The 254 clinics taking part in the study have been assigned to participate in either intervention or act as a comparison, with one third of clinics allocated to each group.
The community monitoring intervention introduces health scorecards that provide information regarding the state of health care in each community, and facilitates interface meetings between community members and health facility staff. During these meetings, information about the state of healthcare is disseminated via a community scorecard and mutual commitments are made to improve services through a joint action plan addressing areas such as staff absenteeism, maternal mortality and vaccination rates. This framework aims to ensure participatory decision-making and hold both healthcare workers and the community mutually accountable, fostering increased access to and utilization of maternal and child health services. Researchers evaluate whether service quality and quantity improve due to the lower costs of collective action introduced through these meetings and the social accountability contract.
The second intervention, non-financial incentives,facilitates a yardstick competition among groups of maternal and child health clinics, and rewards workers at the most improved facilities. The relative rankings of clinics on key measures of such as worker absenteeism, staff attitude and charging of illegal fees will be advertised publicly, and staff at winning clinics will receive letters of commendation from high-ranking politicians, and an award at a public ceremony.
The project is being conducted in partnership with the Government of Sierra Leone and the interventions have been designed with a self-sustainable model for scale-up through the Ministry of Health and Sanitation in mind. Researchers will assess the cost-effectiveness of each intervention, as well as their cost-effectiveness relative to one another, and findings will directly inform the government’s decision to scale up these interventions in future years.
Ashraf, Nava, Oriana Bandiera, and Kelsey Jack. "No Margin, No Mission? A Field Experiment on Incentives for Pro-Social Tasks." Harvard Business School Working Paper, No. 12-008, August 2011.
Martina Bjorkman & Jakob Svensson, 2010. "When Is Community-Based Monitoring Effective? Evidence from a Randomized Experiment in Primary Health in Uganda," Journal of the European Economic Association, MIT Press, vol. 8(2-3), pages 571-581, 04-05.